Perception and awareness of diabetes risk and reported risk-reducing behaviors in adolescents

IMPORTANCE: Lifestyle change is central to diabetes risk reduction in youth with overweight or obesity. Feeling susceptible to a health threat can be motivational in adults. OBJECTIVE: To evaluate associations between diabetes risk perception and/or awareness and health behaviors in youth. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed data from the US National Health and Nutrition Examination Survey 2011 to 2018. Participants included youths aged 12 to 17 years with body mass index (BMI) in the 85th percentile or higher without known diabetes. Analyses were conducted from February 2022 to February 2023. MAIN OUTCOMES AND MEASURES: Outcomes included physical activity, screen time, and attempted weight loss. Confounders included age, sex, race and ethnicity, and objective diabetes risk (BMI, hemoglobin A1c [HbA1c]). EXPOSURES: Independent variables included diabetes risk perception (feeling at risk) and awareness (told by clinician), as well as potential barriers (eg, food insecurity, household size, insurance). RESULTS: The sample included 1341 individuals representing 8 716 794 US youths aged 12 to 17 years with BMI in the 85th percentile or higher for age and sex. The mean age was 15.0 years (95% CI, 14.9-15.2 years) and mean BMI z score was 1.76 (95% CI 1.73-1.79). Elevated HbA1c was present in 8.6% (HbA1c 5.7%-6.4%: 8.3% [95% CI, 6.5%-10.5%]; HbA1c ≥6.5%: 0.3% [95% CI, 0.1%-0.7%]). Nearly one-third of youth with elevated HbA1c reported risk perception (30.1% [95% CI, 23.1%-38.1%), while one-quarter (26.5% [95% CI, 20.0%-34.2%]) had risk awareness. Risk perception was associated with increased TV watching (β = 0.3 hours per day [95% CI, 0.2-0.5 hours per day]) and approximately 1 less day per week with at least 60 minutes of physical activity (β = -1.2 [95% CI, -2.0 to -0.4) but not with nutrition or weight loss attempts. Awareness was not associated with health behaviors. Potential barriers had mixed associations: larger households (≥5 members vs 1-2) reported lower consumption of non-home-prepared meals (OR 0.4 [95% CI, 0.2-0.7]) and lower screen time (β = -1.1 hours per day [95% CI, -2.0 to -0.3 hours per day), while public insurance (vs private) was associated with approximately 20 fewer minutes per day of physical activity (β = -20.7 minutes per day [95% CI, 35.5 to -5.8 minutes per day]). CONCLUSIONS AND RELEVANCE: In this cross-sectional study including a US-representative sample of adolescents with overweight or obesity, diabetes risk perception and awareness were not associated with greater engagement in risk-reducing behaviors in youth. These findings suggest the need to address barriers to engagement in lifestyle change, including economic disadvantage

Association between prediabetes diagnosis and body mass index trajectory of overweight and obese adolescents

BackgroundPrediabetes awareness in adults has been associated with improved weight management. Whether youth with prediabetes diagnosis experience similar improvements is unknown.ObjectiveTo investigate the association between prediabetes identification and body mass index (BMI) trajectory in overweight and obese adolescents.SubjectsYouth who were followed longitudinally in a large academic‐affiliated primary care network and who were overweight/obese while 10 to 18 years old.MethodsRetrospective cohort study. Subjects were categorized as “screened” if at least 1 hemoglobin A1c (HbA1c) result was available. Time series analysis was used to determine the difference in difference (DID) in BMI Z‐score (BMI‐Z) slope before and after HbA1c between: (a) screened youth found to have prediabetes‐range HbA1c (5.7%‐6.4%, 39‐46 mmol/mol) versus normal HbA1c and (b) screened versus age‐matched unscreened obese youth.ResultsA total of 4184 (55.6% female) screened subjects (median follow‐up 9.7 years) were included. In which, 637 (15.2%) had prediabetes‐range HbA1c. Prediabetes was associated with a greater decrease in BMI‐Z slope than normal HbA1c (DID: −0.023/year [95% CI: −0.042 to −0.004]). When compared to age‐matched unscreened subjects (n = 2087), screened subjects (n = 2815) experienced a greater decrease in BMI‐Z slope after HbA1c than unscreened subjects at a matched age (DID: −0.031/y [95% CI ‐0.042 to −0.021]).ConclusionsBMI‐Z trajectory improved more among youth with prediabetes‐range HbA1c but also stabilized in screened youth overall. Prospective studies are needed to identify provider‐ and patient‐level drivers of this observation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156184/2/pedi13028.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156184/1/pedi13028_am.pd

Sex‐based

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166272/1/ijpo12699.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/166272/2/ijpo12699_am.pd

Sex‐based differences in screening and recognition of pre‐diabetes and type 2 diabetes in pediatric primary care

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166272/1/ijpo12699.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/166272/2/ijpo12699_am.pd

Child Opportunity Index and clinical characteristics at diabetes diagnosis in youth: type 1 diabetes versus type 2 diabetes

Introduction Among youth with type 1 diabetes (T1D), longitudinal poor glycemic control is associated with adverse socioeconomic conditions at the neighborhood level. Child Opportunity Index (COI), which encompasses measures of education, health, environment, social, and economic factors, is associated with obesity in youth but has not been evaluated in youth with new-onset T1D or type 2 diabetes (T2D). We hypothesized that lower COI would be associated with adverse clinical outcomes at diabetes diagnosis, and due to differing risk factors and pathophysiology, that youth with new-onset T2D would have lower COI than youth with T1D.Research design and methods Retrospective cohort of youth with new-onset diabetes admitted to a large academic pediatric hospital. COI was compared by diabetes type using t-tests and Χ2 tests. Multivariable linear and logistic regression analyses were used to evaluate associations between COI and clinical characteristics, stratified by diabetes type and adjusted for age and sex.Results The cohort (n=484) differed in race and age by diabetes type (T1D: n=389; 10.0% black, 81.2% white; age 9.6±0.2 years; T2D: n=95; 44.2% black, 48.4% white; age 14.8±0.3 years). Youth with T2D had lower COI (p<0.001). Low COI was associated with diabetic ketoacidosis in T1D and T2D. Black youth with low COI had the highest hemoglobin A1c among youth with T2D and the highest obesity prevalence among youth with T1D.Conclusions COI is associated with differing characteristics at diagnosis in youth-onset T1D and T2D but is worse among youth with T2D overall. These findings underscore the need to address socioeconomic adversity when designing interventions to reduce T2D risk and to improve outcomes at diabetes diagnosis in youth

Real‐world treatment escalation from metformin monotherapy in youth‐onset Type 2 diabetes mellitus: A retrospective cohort study

BackgroundDue to high rates of comorbidities and rapid progression, youth with Type 2 diabetes may benefit from early and aggressive treatment. However, until 2019, the only approved medications for this population were metformin and insulin.ObjectiveTo investigate patterns and predictors of treatment escalation within 5 years of metformin monotherapy initiation for youth with Type 2 diabetes in clinical practice.SubjectsCommercially‐insured patients with incident youth‐onset (10–18 years) Type 2 diabetes initially treated with metformin only.MethodsRetrospective cohort study using a patient‐level medical claims database with data from 2000 to 2020. Frequency and order of treatment escalation to insulin and non‐insulin antihyperglycemics were determined and categorized by age at diagnosis. Cox proportional hazards regression was used to evaluate potential predictors of treatment escalation, including age, sex, race/ethnicity, comorbidities, complications, and metformin adherence (medication possession ratio ≥ 0.8).ResultsThe cohort included 829 (66% female; median age at diagnosis 15 years; 19% Hispanic, 17% Black) patients, with median 2.9 year follow‐up after metformin initiation. One‐quarter underwent treatment escalation (n = 207; 88 to insulin, 164 to non‐insulin antihyperglycemic). Younger patients were more likely to have insulin prescribed prior to other antihyperglycemics. Age at diagnosis (HR 1.14, 95% CI 1.07–1.21), medication adherence (HR 4.10, 95% CI 2.96–5.67), Hispanic ethnicity (HR 1.83, 95% CI 1.28–2.61), and diabetes‐related complications (HR 1.78, 95% CI 1.15–2.74) were positively associated with treatment escalation.ConclusionsIn clinical practice, treatment escalation for pediatric Type 2 diabetes differs with age. Off‐label use of non‐insulin antihyperglycemics occurs, most commonly among older adolescents.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/169332/1/pedi13232_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/169332/2/pedi13232.pd

Text Messages and Financial Incentives to Increase Physical Activity in Adolescents With Prediabetes and Type 2 Diabetes: Web-Based Group Interviews to Inform Intervention Design

BackgroundPhysical activity is a major component of treatment for adolescents with obesity and prediabetes or type 2 diabetes; however, sedentary behavior remains pervasive. An SMS text message–based intervention paired with financial incentives may be an effective way to promote physical activity in this population. ObjectiveThis study aims to obtain end-user feedback on SMS text message content and assess the acceptability of a planned SMS text messaging intervention with financial incentives to motivate youth with prediabetes or type 2 diabetes to increase physical activity. MethodsAdolescents with overweight or obesity and prediabetes or type 2 diabetes who attended a large academic pediatric endocrinology clinic were recruited to participate in group interviews (2-4/group) via videoconferencing. Participants were asked to share their thoughts on the use of SMS text messages and financial incentives to remind and motivate them to be more physically active. They rated and provided feedback on specific messages to be used in clinical trials. Participants were also asked about their personal experience with rewards to motivate behavior change and their anticipated reactions to rewards provided for goal attainment (gain-framing) versus those provided and then taken away if a goal was not met (loss-framing). The interviews were conducted by 2 trained interviewers and a note-taker. Content analysis was used to explore themes. ResultsGroup interviews were completed with 20 participants (11/20, 55% women; 15/20, 75% with type 2 diabetes; 5/20, 25% with prediabetes) with a mean age of 15 (SD 1; range 12-18) years and a mean BMI of 41 (SD 5) kg/m2 (all >95th percentile for age and sex). Most participants were non-Hispanic Black (14/20, 70%) and 10% (2/20) were Hispanics. Participants frequently cited near-continuous smartphone use and agreed that SMS text messages would serve as good reminders to be physically active, but the consensus about the need for short messages was strong. Favorable content included references to what they were likely to be doing when messages were sent (eg, homework or watching television) and messages that were upbeat or informative. Specific physical activity suggestions were rated favorably. Attitudes toward financial incentives varied, with differing opinions about whether loss-framed incentives would be motivating or discouraging. Many participants highlighted the role of intrinsic, rather than extrinsic, motivation in achieving and sustaining behavior change. ConclusionsThe engagement of adolescents with obesity and diabetes or prediabetes allowed for the refinement of SMS text messages for our planned intervention, with an emphasis on short, upbeat, relatable, and informative messages. Although an SMS text messaging intervention using financial incentives to motivate youth with prediabetes or type 2 diabetes to be more physically active is theoretically acceptable, the impact on actual activity levels in this population requires prospective evaluation in a clinical trial